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NICE self-harm guideline

Self-harm in over 8s: long-term management

Key priorities for implementation

The following recommendations have been identified as priorities for implementation

Working with people who self-harm

Health and social care professionals working with people who self-harm should:

aim to develop a trusting, supportive and engaging relationship with them

be aware of the stigma and discrimination sometimes associated with self-harm, both in the wider society and the health service, and adopt a non-judgemental approach

ensure that people are fully involved in decision-making about their treatment and care

aim to foster people's autonomy and independence wherever possible

maintain continuity of therapeutic relationships wherever possible

ensure that information about episodes of self-harm is communicated sensitively to other team members

Psychosocial assessment

Offer an integrated and comprehensive psychosocial assessment of needs and risks to understand and engage people who self-harm and to initiate a therapeutic relationship

Assessment of needs should include:

skills, strengths and assets

coping strategies

mental health problems or disorders

physical health problems or disorders

social circumstances and problems

psychosocial and occupational functioning, and vulnerabilities

recent and current life difficulties, including personal and financial problems

the need for psychological intervention, social care and support, occupational rehabilitation, and also drug treatment for any associated conditions

the needs of any dependent children

Risk assessment

When assessing the risk of repetition of self-harm or risk of suicide, identify and agree with the person who self-harms the specific risks for them, taking into account:

methods and frequency of current and past self-harm

current and past suicidal intent

depressive symptoms and their relationship to self-harm

any psychiatric illness and its relationship to self-harm

the personal and social context and any other specific factors preceding self-harm, such as specific unpleasant affective states or emotions and changes in relationships

specific risk factors and protective factors (social, psychological, pharmacological and motivational) that may increase or decrease the risks associated with self-harm

coping strategies that the person has used to either successfully limit or avert self-harm or to contain the impact of personal, social or other factors preceding episodes of self-harm

significant relationships that may either be supportive or represent a threat (such as abuse or neglect) and may lead to changes in the level of risk

immediate and longer-term risks

Risk assessment tools and scales

Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm

Care plans

Discuss, agree and document the aims of longer-term treatment in the care plan with the person whoself-harms. These aims may be to:

prevent escalation of self-harm

reduce harm arising from self-harm or reduce or stop self-harm

reduce or stop other risk-related behaviour

improve social or occupational functioning

improve quality of life

improve any associated mental health conditions

Review the person's care plan with them, including the aims of treatment, and revise it at agreed intervals of not more than 1 year

Care plans should be multidisciplinary and developed collaboratively with the person who self-harms and, provided the person agrees, with their family, carers or significant others*. Care plans should:

identify short-term treatment goals (linked to the long-term goals) and steps to achieve them

identify the roles and responsibilities of any team members and the person who self-harms

include a jointly prepared risk management plan

be shared with the person's GP

Risk management plans

A risk management plan should be a clearly identifiable part of the care plan and should:

address each of the long-term and more immediate risks identified in the risk assessment

address the specific factors (psychological, pharmacological, social and relational) identified in the assessment as associated with increased risk, with the agreed aim of reducing the risk of repetition of self-harm and/or the risk of suicide

include a crisis plan outlining self-management strategies and how to access services during a crisis when self-management strategies fail

ensure that the risk management plan is consistent with the long-term treatment strategy

Inform the person who self-harms of the limits of confidentiality and that information in the plan may be shared with other professionals

Interventions for self-harm

Consider offering 3 to 12 sessions of a psychological intervention that is specifically structured for people who self-harm, with the aim of reducing self-harm. In addition:

The intervention should be tailored to individual need and could include cognitive-behavioural, psychodynamic or problem-solving elements

Therapists should be trained and supervised in the therapy they are offering to people who self-harm

Therapists should also be able to work collaboratively with the person to identify the problems causing distress or leading to self-harm

Do not offer drug treatment as a specific intervention to reduce self-harm

Treating associated mental health conditions

Provide psychological, pharmacological and psychosocial interventions for any associated conditions, for example those described in the following published NICE guidance:

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

Disclaimer: This guide for healthcare professionals on identifying medical comorbidities in autism spectrum disorders has been developed by Treating Autism.
Source: Treating Autism (www.treatingautism.org.uk/wp-content/uploads/2016/11/comorbidities_guide_4p.pdf). Date of preparation: October